Editorial Board Dengue Vaccine – So Near, Yet So Far · Studies code-named CYD14 in Asia and...

BERITA MPA – FEBRUARY 2016 • 1

THE MALAYSIAN PAEDIATRIC ASSOCIATION FEBRUARY 2016 FOR MEMBERS ONLY

Editorial Board

Datuk Dr Zulkifli IsmailDr Selva Kumar SivapunniamDr Yong Junina Fadzil

MPA 2015 – 2017EXECUTIVE COMMITTEE

PresidentDr Thiyagar Nadarajaw

Immediate Past PresidentDr Kok Chin Leong

Vice-PresidentAP Dr Muhammad Yazid Jalaludin

SecretaryAP Dr Tang Swee Fong

Asst SecretaryDr Selva Kumar Sivappuniam

TreasurerDato’ Dr Musa Mohd Nordin

Committee MembersDatuk Dr Zulkifli IsmailDatuk Dr Soo Thian LianDr Koh Chong TuanDr Hung Liang ChooDr Noor Khatijah NuraniProf Dr Wan Ariffin Abdullah

Honorary Auditors Dr Rosalie YipDr Rus Anida Awang

The Berita MPA is published for members to keep them informed of the activities of the Association and to keep up with developments in paediatrics and child health.

The views and opinions in all the articles are entirely those of the authors unless otherwise specified.

We invite articles and feedback from readers – Editor <[email protected]>

3rd Floor (Annexe Block), National Cancer Society Building, 66, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur.

Tel: 2691 5379 / 2698 9966 Fax: 2691 3446 E-mail: [email protected] Web page: www.mpaweb.org.my

Affiliated to:

• MalaysianCouncilForChildWelfare

• ASEANPediatricFederation

• AsiaPacificPediatricAssociation – APPA (Previously Association of

Pediatric Societies of the South East Asian Region – APSSEAR)

• InternationalPediatricAssociation(IPA)

continued on page 3…

Everybody knows what dengue infection is and everybody would want to be protected against it. We have waited a long time for the vaccine to come and now that it is here, many are hesitant to use it. Although passed phase 3 trials and tested in Asian and Latin American countries, there is a hesitation in getting the vaccine registered.

Mexico was the first country to register Dengvaxia, Sanofi-Pasteur’s quadrivalent recombinant live-attenuated chimeric vaccine using yellow fever virus as a backbone, on 8 December 2015, followed by the Philippines on 22 December and Brazil on 28 December. Although the price of the vaccine has never been stated by the company, many are anticipating the worst in pricing considering the company has invested 20 years and more than USD 1.5 billion to develop it.

Three doses, 6 months apartGiven subcutaneously in three doses 6 months apart, a number of studies have been done in Asia and Latin America to look at immunogenicity and reactogenicity of Dengvaxia.

Studies code-named CYD14 in Asia and CYD15 in Latin America report an overall vaccine efficacy (VE) of 65.6% (95% CI 60.7-69.9). Individual serotype efficacy was •58.4%forDEN-1,•47.1%forDEN-2,•73.6%DEN-3and•83.2%DEN-4.

VE against severe dengue was 93.2%, againstDHF(WHOcriteria)92.9%andagainst hospitalized cases 80.8%.

Dengue Vaccine – So Near, Yet So Far

STOPDENGUE

2 • BERITA MPA – FEBRUARY 2016

Overcoming Challenges Together in 2016...

ReportFrom The President

Happy New Year! Let me begin by wishing you a Happy and ProsperousNewYear.

Let us leap into 2016 and continue our role advocating for the right to health of children we serve, in line with MPA’s motto- “Working for Children:TheNation’sFuture”.

We have a responsibility to play advocacy roles required to ensure that our health systems are strengthened to achieve universal health coverage in line with the Sustainable Development Goal (SDGs)strategiesbyUnitedNations.

Challenging times in Ministry of Health (MOH) TherecentbudgetcutinMOHwould inevitably result in further cutsinhealthexpenditure.Onemust be judicious in using the existing fund to avoid unnecessary wastage in particular, extraneous routine investigations, without compromising patient care.

Despite these hindrances, let us face the predicament and move forward to perform at our highest ability to prevent illness, treat children to the best of our ability, reduce morbidity and prevent mortality.

Ethical practiceThe basic principles of medical ethics should be observed. In paediatrics it is unique. Unlike in adult medicine where it is a physician-patient relationship; in paediatrics it is the paediatrician-patient-parent relationship. Medical decisions are made best with the rights and obligations of each of these individuals kept in mind as

well as an understanding of widely accepted principles of medical ethics. We must observe the rights of parents, children, and adolescents in our medical decision-making.

Social media is not making it easier for us. We often encounter social media displaying pictures of children which is clearly against Malaysian Child Act. We should be aware and alert the authorities to put a stop to this

Perhaps we ourselves should be cautious when commenting about our patients in social media…

Child safety and maltreatmentAccidental injuries and drowning still top significant lives lost. We have and are still losing young children to preventable injuries. Children are drowning. As what was mentioned by a senior colleague of ours, there is at least 1 child dying of drowning every day in our country. That is the sad truth…

Let us ramp up out effort to educate parents on child safety issues opportunistically during every contact with parents during our daily practice. Give out anticipatory guidance.

The country (still) needs more paediatriciansWe need more paediatricians to serve the children & adolescents ofMalaysia.MOHhasintroducedparallelpathwaystofacilitateMOsto take up various specialty.

The word ‘doctor’ though refers to a physician; it is derived from the Latin docere,“toteach”.Doctorsare

obliged to contribute to education and training of junior doctors.

As paediatricians, perhaps we could encourage our juniors to take up paediatrics as their specialty. We could create a conducive environment in the department to sow the seed of interest and guide them to reach their goal of becoming a paediatrician. We must try to inspire them. Try to be good role models. We should drown our ego and practise with humility.

Paediatricians amongst us had teachers who guided us in the past. It’s payback time for us to train others to become paediatricians. The career cycle does not complete till you ‘create’ another paediatrician under your guide. It is reassuring to see there are many doing so. However we need more…

Let us be as selfless as possible in our daily duties. Be it through MRCPCH or Masters Programmes. It is also my wish that children get the best service available …

I have learned that the inherent drive and dedication of the paediatric fraternity comes from a history of nurturing by our senior paediatricians, and I extend my special thanks to them; some of whom will be retiring this year. They are a group with exceptional aptitude and sense of service. I believe retirement would not stop these exceptional characters from continuing to serve MPA and the children of our children in many other ways.

Measles vaccine changes

Recently Ministry of Health made some changes to our measles immunisation schedule. You could


ReportUpdate

refer to the circular by the Director General of Health for further details (Ref: KKM 600-1/2/3(10) dated 17 December 2015) or refer to page 7 of this issue of BMPA.

Vaping – the lesser evil?In the past 3 months, the media is abuzz with the Vape controversy. It has taken the social media by storm. There have been meetings and extensive debates between the anti vapers vs vapers. We already have one evil in the form of tobacco smoking which contributes to a myriad of childhood respiratory illnesses. It has become almost impossible to rid of smoking. HoweveritisreassuringthatMOHhastakenafirmstandonthis.i.evaping is not safe and in fact injurious to health. Though it seems impossible for total ban, it is hoped that the sale will be regulated efficiently. A few states have also banned vape.

Free access to on-line journals As promised this, by now members would have received notification from MPA secretariat regarding the details on accessing this online web.

Reaching outOnceagainIwanttoreiteratethatMPAencouragesmembers,new as well as seasoned to share their views, experience or expertise as volunteers to carry out MPA activities. All MPA need is at least 1 or more paediatricians or paediatric medical officers in every state to spend a few valuable hours a month to make a difference at ground level to promote child health in their respective states. Believe me; once you start you will see how youhaveinspiredmanymoretofollowsuitandyour“goodness”multiplies.JustlikethePiedPiperofHamelin(Notratsthough!)Startvolunteering and you will experience immense satisfaction looking at the outcome. The only side effect is, it may become a habit- which is of course a good blessing. So, please volunteer. Your assistance is greatly valued.

38th MPA congress Ournextcongressthemed“PaediatricGastroenterology,Hepatology&Nutrition”willbeheldinHolidayInnMalaccafrom3-6th August 2016. Though we had ideas to take it further south to Johor, unfortunately we could not identify a suitable venue. Thus, we settled for the beautiful Heritage City of Malacca. The Scientific Committee is working diligently to bring to our delegates a wide variety of speakers and topics.

OnceagainIwishyouablessed,successfulandhealthy2016.2

FrompooleddatapublishedinNEJMJuly2015, efficacy was better in dengue sero-positive subjects (VE 81.9%) compared with dengue sero-negative subjects (VE 52.5%). A total of 25 clinical studies (20 completed, 5 ongoing) in 15 countries and 40,000 subjects have been conducted to show the efficacy of the vaccine. There were slight differences between the Asian and Latin American subjects. While the efficacy against symptomatic dengue (56.5% Asian, 60.8% Latinos) and severe dengue (80% Asian, 95% Latinos) were similar, the decrease in hospitalized dengue cases varied a bit (67.2% Asian, 80.3% Latinos). Among the 2-5 year olds, CYD-14 Asian group noted higher hospitalized cases in the vaccinated group.OtherCYDstudieswereCYD23/57in Thailand, CYD 22 in Vietnam, CYD 47 India and CYD 17 Australia.

Adverse reactionsAdverse reactions were mainly headache, myalgia, injection site pain, malaise, asthenia and fever. There was no documented viscerotropism or neurotropism, nor hypersensitivity reactions.

Why the hesitation?Nowthatthelong-awaiteddenguevaccine has arrived, why are we so hesitant to license and use it here? Perhaps one reason is that the followup of the study cohorts had not been long enough and without the ‘confidence’ ofFDAorEMEAapproval,manyAsianministries of health, Malaysia especially, do not want to use it as a clinical trial on theirpopulations.Oncelicensed,withthe high knowledge on dengue and its complications, there would be intense pressure on government to introduce it in the national program.

Another reason could be that even with vaccination in place, other vector control measures cannot be stopped, resulting in no financial saving. With the dismal efficacy among children, Dengvaxia is currently recommended for those above age 9 years until 45 years.

While we have a safe and efficacious vaccine, should we wait for ideal results before we start using it to protect our population? With the shift of mortality from children to young adults, using it for individuals above age 9 years would help reduce hospitalization and severity of dengue fever in the target age groups. Thenearestcompetitor,DENVaxbyTakeda will take a few more years to be released. 2

Zulkifli [email protected]

N.Thiyagar President 2015-2017

[email protected]

… from page 1


The Department of paediatrics, Hospital Sultanah Bahiyah (HSB), Alor Setar, Kedah Darul Aman in collaboration with the Malaysian Paediatric Association (Kedah Subcommittee) conducted the “Surgical Paediatrics Update 2015”onthe4thOctober2015.Theone day programme was dedicated to address the common surgical conditions in children. An estimated 200 participants from Kedah, Perlis and Penang attended this update.

DrN.Thiyagarwelcomedtheparticipantsandthanked all the speakers from various departments who took the opportunity to share their knowledge on the latest update from their paediatric surgical perspective.

Datin Dr Siti Sabzah, senior consultant Paediatric ORLSurgeonbeganthescientificsessionwiththe topic ‘Common Paediatric ORL Conditions in Neonates’. She gave an enlightening talk on the currentissuesofORLrelatedproblems.ThistalkwasfollowedbyDrPriatharisiny,ORLSurgeon on Foreign Body Inhalation. She presented the various modes of presentation, a display of different types of foreign bodies and its management. Dr Regunathan Villanayer; a well-known senior consultant plastic surgeon presented a topic on Managing cleft lip/ palate and Paediatric burn management.DrNikFatimahSalwatithendiscussedonRadio-imaginginacute surgical emergencies in children.

The update continued with the presentation by pediatricsurgeons,Dato’Mr.MohanNallusamywhospoke on Acute Surgical Emergencies in Neonates followed by Miss Tammy Teoh Han Qi who presented on Acute Abdomen in the pediatric age group.

The consultant paediatric intensivist, Dr Choong Pheik Sian started the afternoon session by discussing the challenges in Managing raised intracranial pressures in children.Dr.MuzalihaMohamedNor,

ophthalmologist spoke on Acute paediatric eye conditions and followed by Miss Haryati M. Yusof, orthopedic surgeon who shared her experience on Congenital Orthopedic Problems. Dr Azilah Mohd Ali, Pediatric Dental Surgeon then concluded the afternoon session with the topic Common Pediatric Dental Conditions.

There were also quiz sessions in between the talks and winners were given small mementoes.

The “Surgical Paediatric Update 2015”provideda great opportunity to medical officers and paramedics to enhance their knowledge on the current paediatric surgical problems as shared by senior consultants from Hospital Sultanah Bahiyah.

During her closing remark, Datin Dr Siti Sabzah emphasized the need of comprehensive care for all our children including the need of early rehabilitation and intervention. It is important as these children will be our future leaders and our care givers in the future.

In conclusion, it was an astoundingly successful session and participants voiced their wish to see it as an annual event and the collaboration with various specialties will continue. 2

Surgical Paediatric Update 2015: Hospital Sultanah Bahiyah, Kedah4th October 2015

Report

Mohd Shahfi Fauzee B Ismail, MedicalOfficer/Priatharisiny, PaediatricORLSurgeon–PaediatricORL

Department Hospital Sultanah Bahiyah, Kedah Darul Aman


Kids Fitness Club

Why the surge in incidence of childhood obesity over the past 3 decades?Obesityisnotsolelyaboutgenetics or overeating. Genetics may play a part but genetic predisposition can be modified favourably by environmental factors. Being overweight or obese is the result of “caloric imbalance”—toofewcaloriesexpended for the amount of calories consumed. Consumption of calorie packed food compounded by sedentary lifestyle of modern era is the crux of the problem.

Why must we act?Overweightandobesechildrenare at risk for diabetes and cardiovascular diseases at a youngerage.Overweightandobesity as well as their related diseases are preventable. Prevention of childhood obesity therefore is of high priority.

The Hospital Lam Wah Ee Kids Fitness Club spearheaded by Dr. Adele Tan (Senior Consultant Paediatrician) aims to tackle this important issue head on. The working committee of this club includes our in house Chief Dietician, Chief Physiotherapist, PaediatricNursesandvolunteers.

HLWE Kids Fitness Club (A community project of Hospital Lam Wah Ee)Aim: Motivate overweight kids to achieve a healthy lifestyle through

participation in fun and engaging fitness activities.

Ourtagline:“ HEALTHY WEIGHT, HEALTHY KIDS”

Road Map• Structuredprogramme

throughout the year guided by the opportunity for members to have an interactive discourse with committee members through a website and whatsapp group

• Monitoringofprogressofweight reduction and health through self-appraisal and at quarterly meets in Lam Wah Ee hospital

Proposed activities include:1. Guided shopping trips to buy

healthy food and drinks2.Fitnessbootcamps3. Hospital visits to see for

themselves the devastating consequences of obesity related diseases like diabetes, strokes and heart diseases

4.Fieldtripswithemphasisonback to nature activities

5. Exercise camps6. Promote greater awareness

of obesity and obesity related disease through workshops and public talks.

7. Publicity campaigns to disseminate information and educate the community at large

Forastart,membershipisopento primary school children but we hope to open membership to adolescents in the near future.

Starting the Hospital Lam Wah EeKidsFitnessClubisthefirstsmall step towards a larger and more impactful anti-obesity programme. In order for the programme to succeed;

1. Society at large must be aware of the problem.

2. Information must be readily available through all channels of communication especially through social media.

3. Education is the key and should start as early as possible both in homes and in schools

4. Policy makers must be convinced of the seriousness of the problem. Healthy kids make healthy adults. A population with poor health due to chronic obesity related disease is a drain on the health resources of the country.

5. Health care workers especially paediatricians have an important role to play and should lead the way in this battle against childhood obesity.

We hope that the Hospital Lam WahEeKidsFitnessClubwillbea catalyst for other organisations to start similar programmes, with the most desirable outcome of all being the implementation of anti-obesity programmes in schools nationwide. 2

According to theWorld HealthOrganisation (WHO), childhood obesity is one ofthe most serious public health challenges of the 21st Century. In 2013, the number of overweight children under the age of five globally is estimated to be over 42 million with a high proportion (about 31 million) coming from developing countries. Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years.

The National Health andMorbidity Survey (NHMS) in 2011 found that childhoodobesity affects one in seven children in Malaysia. More recently, a cross-sectional study of 8705 Malaysian school children and adolescents initiated in 2013 revealed that 1 in four children were overweight or obese (see page 8-9 in this issue of BMPA).

Proposal

Adele Tan Hospital Lam Wah [email protected]


Toxic Stress and Resiliency?That was the question I asked when the American Academy of Pediatrics (AAP) sent an invitation to participate in a forum at the AAP Experience NationalConferenceinWashington,DC24-27th

October2015.InvitedasAsiaPacificPediatricAssociation (APPA) President to give an insight into the prevention of toxic stress and promotion of resiliency, I had to understand what exactly thesemeant!AskingPaediatriciansworkingonchild abuse and neglect gave a small insight into the topic but it was hardly enough. Most did not know what toxic stress really is; resilience they can understand. That was when I turned to Dr Jonathan Klein from the AAP who then sent me a website on these topics that I found so interesting.

Toxic stress and resiliency are new areas to paediatricians even in the US although the psychologists had been writing all about it for the past decade. It was time that Paediatricians started to understand it and learn to apply it in their daily practice. Studying the websites, it became clear to me that there was so much of science involved. What I wanted to know was how we as Paediatricians can apply the science to our daily practice.

Stress continuumWe all know that stress can be positive, negative or just tolerable. Toxic stress is part of this continuum - a chronic stress situation that the child cannot get out of. Under ideal circumstances, the child’s immediate adult carers would provide the protection and support to ameliorate this stress. In toxic stress, there is no parental nor social support to save him to provide a way out. We sometimes forget the interaction of the child with his immediate family, extended family, school teachers, and other adults like our maids who are supposed to provide a stable and safe environment for the child. Persistently abused or exploited children, those in refugee camps, in war

zones, constantly bullied, etc are subjected to toxic stress. Different children respond differently to these stress situations giving different levels of resilience.

Paediatricians’ roleOurroleaspaediatriciansistoidentifythesestresses which manifest in many ways, look at ways to help the children and help develop the social structure to support resilience in these children. These are huge expectations that few are willing orabletomeet!Inallourcountries,therearesocial welfare departments within the government machinery that need to be primed towards providing this sort of support.

As in any symposium of this nature, nothing concrete can be expected but the awareness of the presence of toxic stress and the knowledge about agencies and people who are available to help would be a good enough outcome. It certainly opened my eyes to the different types of stresses, various presentations of toxic stress and the avenues that are open to Paediatricians to help. We may even enlist the help of the AAP to conduct similar symposia at our local or regional meetings to cascade this message on toxic stress and resiliency. To be effective, these meetings should be attended by others who care for children too, eg, child psychologists, welfare department officials, health officials, educationists, nurses’ associations, public health staff, etc so that the Paediatricians are not the only ones shouting about this.

We may not be able to do it all in our countries but we have a target to achieve and a light to follow. The AAP has shown us this light and set our target. 2


APPA President

Report

L-R: Robert Block, Leyla Namazova-Baranova (Russia), Errol Alden,

Ann Masten, Zulkifli Ismail, Margarita Ramona (Argentina).Robert Block (R) introducing the panelists representing different regions.


Summary of current vaccination situation

Year 2015 saw the shortage of the pentavalent DTaP-IPV-Hib and hexavalent DTaP-IPV-Hib-HepB vaccines in both the public and private sectors. There was a shortage of varicella vaccine produced by GSK and of the combination MMRV vaccines too. Add the recent sporadic outbreaks of measles especially among children younger than age 12 months, Malaysia cannot achieve measles elimination. Combined with anti-vaccine sentiments and vaccine hesitancy and refusal among young Gen Y parents, vaccine advocacy is at its most challenging time.

In facing the vaccine shortage and measles outbreaks, the following decisions were made by our Ministry of Health to be implemented nationwide until further notice:•DefertheboosterdoseofDTaP-IPV-Hibtoage

2 years to give some breathing space,•MOHwillallocate10%ofallstocksitgetstothe

private sector that will be distributed nationwide,

•PrivatepractitionerswhodonothaveDTaP-IPV-Hibvaccines to refer the parents to the nearest Klinik Kesihatan, and advise parents about the deferment of booster dose,

•MMRwillbegivenat9monthsand12monthswitheffect from April 2016.

•SchoolhealthMRvaccinationwillcontinuetillyear2021, after which it will stop, leaving only two doses of MMR at 9 and 12 months,

Despite unavailability of pentavalent vaccine, private practitioners should continue to explain about and offer other vaccines that are not in the NationalImmunisationProgram.Thesemayincludepneumococcal conjugate (PCV), rotavirus (RV), hepatitis A, influenza and meningococcal conjugate vaccines. 2

French couple given suspended jail time for refusing to vaccinate children

AFrenchcouplehavereceivedatwo-monthsuspended jail sentence for refusing to vaccinate their two young children. Marc and Samia Larere were given the sentence in the criminal court at Auxere, 175 kilometres south of Paris, on Thursday.

The case has attracted widespread attention in Francewherestrictvaccinationlawsmandatechildhood immunisation. The court was told the couple refused to vaccinate their children, aged three and 15 months, against polio, tetanus and diphtheria because they believed the vaccine would do more harm than good.

InFrance,proofofvaccinationisrequiredbeforea child can attend day care, school or sports programs. When the couple could not provide proof their children had been immunised, they were initially charged with neglecting their children’s health, an offence that carries a maximum of two years in prison and a $46,000 fine.

The couple argued they refused to use the combined polio, tetanus and diphtheria vaccine becauseitcontaineda“toxicproduct”.Thecharge was downgraded to “refusing to undergo mandatoryvaccination”,whichcarriesa

Editor’s note:This is an interesting article regarding the enforcement of vaccination among parents whorefuse.FranceandAustraliahavesimilarlaws that either prohibits children from entering school or charging them for neglecting to look after their children's health. The US is mulling over the issue as a few other EU countries. Malaysia does not have that in our Child Act although it can be interpreted as neglect. You can send your opinions if you feel strongly one way or the other on this issue.

[email protected]


for The Executive Committee

maximum of six months’ imprisonment and a $5800 fine.

NewvaccinationlawscameintoeffectinAustralia on January 1, requiring families to immunise their children or miss out on subsidised childcare, worth thousands of dollars a year. The same rule applies to the family tax benefit part A supplement. 2

The Sydney Morning Herald

In response to queries from Paediatricians and General Practitioners, we are summarising the vaccination changes with the approval of the Vaccine Preventable Diseases Sector, Disease Control Division of Ministry of Health Malaysia.

Vaccine Update


Summary

Key Findings

Northern(n=2177, 25.0%)

Central(n=1791, 20.6%)

Southern(n=1729, 19.9%)

East Coast(n=1453, 16.7%)

East Malaysia(n=1555, 17.9%)

MyBreakfast Study, the first comprehensive nationwide study on breakfast habits in the country, was carried out by the Nutrition Society of Malaysia, in 2013.

A multi-stage sampling method was carried out based on geographical location and ethic group distribution, utilising the Population and Housing Census 2010.

The study aimed to determine breakfast habits, including the types of food and beverages that are most commonly consumed at breakfast among these school children. In addition, bodyweight status, physical activity level and daily dietary intakes of the children were measured and associations with breakfast habits were examined.

There was a higher percentage of secondary school children with low

physical activity level when compared with primary school children

There was a higher prevalence of overweight/obesity among school children with low (27.1%) compared to children with medium (25.7%) and high physical activity level (23.3%).

Among breakfast skippers, there was a higher proportion of children with low physical activity level (42%) than breakfast eaters (32.5%).

8705 primary and secondary

school children

More boys were overweight

than girls

The prevalence of overweight & obesity

was similar among secondary school

children and primary school children

More girls skipped breakfast

than boys

� High proportion of overweight and obesity among children

� Physical activity level among the children was low

� High proportion of breakfast skippers among school children

64.1% primary school children

35.9% secondary school children

28.4% of the children were either overweight or obese

26.4% 22.5%

>

32.9% 24.7%

>1 In 4 children skipped

breakfast24.6% of school children aged 6 – 17

years skipped breakfast ≥ 3 days a week

Breakfast skippers were 1.34 times more likely to be

overweight/obese**adjusted for potential confounders including age, sex, ethnicity, father’s education level, income and

physical activity

1 In 3 school children had Low physical activity level

~

>

28.8% 28.3%

Key Findings

Breakfast contributed to 26.8% of the total daily energy intake of the children, 21.4% of daily protein intake and 29.1% of fat intake. It can be noted breakfast contributed to about 25% of the total daily energy, protein and fat intake.

All the micronutrients (except vitamin A) contributed to more than 25% of the daily nutrient intake.

• Only 25% of primary school & 19% of secondary school children consumed wholegrain.

• Almost all the children studied (over 99%) did not meet the recommended intake of 48 g/day.

• Even among whole grain consumers, the mean intake was about 9 g/day, well below the recommended intake.

• Wheat was the main source of whole grain intake. • Ready-to-eat cereal was the main source of wholegrain foods

(see pie charts on right).

Malted beverages contributed only 5.7% to daily energy intake in consumers but provided 19 – 26% to daily intakes of calcium and B vitamins.

� Contribution of breakfast to daily nutrient intake

Breakfast with RTEC contributed a greater amount of daily micronutrients than other breakfasts

� Top 5 most commonly consumed breakfast foods and beverages

� About 18% of the children consumed ready-to-eat-cereals (RTEC)

� Malted drink consumers had similar total energy intake but higher micronutrient intakes than non-consumers

� Wholegrain consumption among children was very low

1. Bread

2. Eggs

3. Chicken/meat

4. Nasi lemak

5. Fried rice

1. Malted beverage

2. Tea/coffee

3. Ultra-heat treated milk

4. Powdered milk

5. Fruit drink/cordial

Common breakfast foods, % (n=2680)

Common breakfast beverages, % (n=2680)

Percent contribution of breakfast to total micronutrient intake among RTEC consumers and other breakfast consumers

43.2 34.6 36.8

49.2 47.1 41.6

33.6 33.2 24.9

37.5 33.9 30.8

Calcium Iron Vitamin C Thiamin Riboflavin Niacin

RTEC consumers Other breakfast consumers

Chicken/meat, 22.5

Nasi lemak, 21.5

Fried rice, 20.6 Processed fish,

18.1

Fried noodle, 15.8

RTEC, 14.6

Unleavened bread, 12.5

Plain rice, 10.8

Biscuit, 10.0

Kuih, 9.5

Processed chicken/meat, 8.6

Noodle, 8.3

Bread, 38.9

Eggs, 30.1

Malted beverage, 60.6

Tea/coffee, 24.0

UHT milk, 14.4

Powdered milk, 12.8

Fruit juice/drink/cordial, 5.3

Soya milk, 1.7

Flavoured milk, 1.6

Carbonated drink, 0.6

Yogurt/cultured milk, 0.4

Contribution of breakfast to total daily micronutrient intake (n=2680)

29.2

22.6

33.4

35

32.4

35.8

39.2

26.7

23.5

% from breakfast

Vitamin A Vitamin C Thiamin Riboflavin Niacin Calcium Iron Phosphorus Sodium


26.0

19.4

19.5

21.3

12.8

5.7

% from malted drink

Contribution of malted beverage to total daily energy and micronutrient intake Energy Iron Calcium Niacin Riboflavin Thiamin

RTEC

68.6

Hot cereal 18.6

Biscuits 8.7

Bread 1.8

Others 1.6

Rice 0.6

Pasta/noodle 0.1

Primary school children

Sources of wholegrain foods, %

Bread 4.9

Others 2.0

Rice 0.5

Pasta/ noodle 0.2

Secondary school children

Hot cereal24.6

Biscuits10.9

RTEC 56.9

MyBreakfast Study of School Children:

Summary, key findings and recommendations

• Findings from this study should be utilised by relevantministries, agencies and other stakeholders to develop andimplement appropriate intervention programmes to improvethe high prevalence of overweight and obesity observedamongthefullrangeofschool-goingchildren,fromprimarytosecondaryschool.Urgentinterventionprogrammesshouldbesystematicallyimplementedthroughoutthecountry,directedatbothdietaryhabitsandphysicalactivitylevel.

• Interventionstopromoteregularbreakfastconsumptionshouldbeoneoftheapproachesundertaken.

• Nationaldietaryguidelinesshouldincluderecommendationsonconsumingnutritiousfoodsandbeveragesforbreakfastalongwith recommended serving size to help educate children onhowtoachieveabalancedbreakfast.

• Greater efforts must be undertaken to increase nutritioneducationinschoolsonthehealthbenefitsofwholegrainandhowtoidentifywholegrainfoods.Inaddition,stepscouldbe

taken by the regulatory authority in Malaysia to encouragemanufacturerstoaddorincreasewholegraininproducts.

• Participation in physical education should be compulsory foreverychildinschoolandideallyshouldbetaughtbyatrainedteacher.Classesintendedforphysicalactivityeducationshouldbestrictlyutilisedforthispurpose.

• Nutritionistsmustbeassignedtoeffectivelyimplementnutritionrelated activities in schools, including carrying out nutritioneducation activities, various nutrition promotion activities,monitoring and referral of under-and over-nourished childrenandensuringimplementationofschoolcanteenguidelines.

• Parents shouldbe rolemodelsandbeactively involved inallefforts to promote healthy eating and active living amongchildren. Investing in the nutritional wellbeing of childrentodayistheonlywaytoensureahealthiergenerationofadultMalaysianstomorrow.

Recommendations

Tee ES, Mohd Nasir MT, Norimah AK, Hamid Jan JM, Tan SY, Appukutty M, Nurliyana AR, Thielecke F, Hopkins S, Ong MK and Ning C

Nutrition Society of Malaysia MyBreakfast Study Research Committee

For more information, please email Dr Tee E Siong: [email protected]

From NSM


Summary

Key Findings

Northern(n=2177, 25.0%)

Central(n=1791, 20.6%)

Southern(n=1729, 19.9%)

East Coast(n=1453, 16.7%)

East Malaysia(n=1555, 17.9%)

MyBreakfast Study, the first comprehensive nationwide study on breakfast habits in the country, was carried out by the Nutrition Society of Malaysia, in 2013.

A multi-stage sampling method was carried out based on geographical location and ethic group distribution, utilising the Population and Housing Census 2010.

The study aimed to determine breakfast habits, including the types of food and beverages that are most commonly consumed at breakfast among these school children. In addition, bodyweight status, physical activity level and daily dietary intakes of the children were measured and associations with breakfast habits were examined.

There was a higher percentage of secondary school children with low

physical activity level when compared with primary school children

There was a higher prevalence of overweight/obesity among school children with low (27.1%) compared to children with medium (25.7%) and high physical activity level (23.3%).

Among breakfast skippers, there was a higher proportion of children with low physical activity level (42%) than breakfast eaters (32.5%).

8705 primary and secondary

school children

More boys were overweight

than girls

The prevalence of overweight & obesity

was similar among secondary school

children and primary school children

More girls skipped breakfast

than boys

� High proportion of overweight and obesity among children

� Physical activity level among the children was low

� High proportion of breakfast skippers among school children

64.1% primary school children

35.9% secondary school children

28.4% of the children were either overweight or obese

26.4% 22.5%

>

32.9% 24.7%

>1 In 4 children skipped

breakfast24.6% of school children aged 6 – 17

years skipped breakfast ≥ 3 days a week

Breakfast skippers were 1.34 times more likely to be

overweight/obese**adjusted for potential confounders including age, sex, ethnicity, father’s education level, income and

physical activity

1 In 3 school children had Low physical activity level

~

>

28.8% 28.3%

Key Findings

Breakfast contributed to 26.8% of the total daily energy intake of the children, 21.4% of daily protein intake and 29.1% of fat intake. It can be noted breakfast contributed to about 25% of the total daily energy, protein and fat intake.

All the micronutrients (except vitamin A) contributed to more than 25% of the daily nutrient intake.

• Only 25% of primary school & 19% of secondary school children consumed wholegrain.

• Almost all the children studied (over 99%) did not meet the recommended intake of 48 g/day.

• Even among whole grain consumers, the mean intake was about 9 g/day, well below the recommended intake.

• Wheat was the main source of whole grain intake. • Ready-to-eat cereal was the main source of wholegrain foods

(see pie charts on right).

Malted beverages contributed only 5.7% to daily energy intake in consumers but provided 19 – 26% to daily intakes of calcium and B vitamins.

� Contribution of breakfast to daily nutrient intake

Breakfast with RTEC contributed a greater amount of daily micronutrients than other breakfasts

� Top 5 most commonly consumed breakfast foods and beverages

� About 18% of the children consumed ready-to-eat-cereals (RTEC)

� Malted drink consumers had similar total energy intake but higher micronutrient intakes than non-consumers

� Wholegrain consumption among children was very low

1. Bread

2. Eggs

3. Chicken/meat

4. Nasi lemak

5. Fried rice

1. Malted beverage

2. Tea/coffee

3. Ultra-heat treated milk

4. Powdered milk

5. Fruit drink/cordial

Common breakfast foods, % (n=2680)

Common breakfast beverages, % (n=2680)

Percent contribution of breakfast to total micronutrient intake among RTEC consumers and other breakfast consumers

43.2 34.6 36.8

49.2 47.1 41.6

33.6 33.2 24.9

37.5 33.9 30.8

Calcium Iron Vitamin C Thiamin Riboflavin Niacin

RTEC consumers Other breakfast consumers

Chicken/meat, 22.5

Nasi lemak, 21.5

Fried rice, 20.6 Processed fish,

18.1

Fried noodle, 15.8

RTEC, 14.6

Unleavened bread, 12.5

Plain rice, 10.8

Biscuit, 10.0

Kuih, 9.5

Processed chicken/meat, 8.6

Noodle, 8.3

Bread, 38.9

Eggs, 30.1

Malted beverage, 60.6

Tea/coffee, 24.0

UHT milk, 14.4

Powdered milk, 12.8

Fruit juice/drink/cordial, 5.3

Soya milk, 1.7

Flavoured milk, 1.6

Carbonated drink, 0.6

Yogurt/cultured milk, 0.4


29.2

22.6

33.4

35

32.4

35.8

39.2

26.7

23.5

% from breakfast

Vitamin A Vitamin C Thiamin Riboflavin Niacin Calcium Iron Phosphorus Sodium


26.0

19.4

19.5

21.3

12.8

5.7

% from malted drink

Contribution of malted beverage to total daily energy and micronutrient intake Energy Iron Calcium Niacin Riboflavin Thiamin

RTEC

68.6

Hot cereal 18.6

Biscuits 8.7

Bread 1.8

Others 1.6

Rice 0.6

Pasta/noodle 0.1

Primary school children

Sources of wholegrain foods, %

Bread 4.9

Others 2.0

Rice 0.5

Pasta/ noodle 0.2

Secondary school children

Hot cereal24.6

Biscuits10.9

RTEC 56.9

MyBreakfast Study of School Children:

Summary, key findings and recommendations

• Findings from this study should be utilised by relevantministries, agencies and other stakeholders to develop andimplement appropriate intervention programmes to improvethe high prevalence of overweight and obesity observedamongthefullrangeofschool-goingchildren,fromprimarytosecondaryschool.Urgentinterventionprogrammesshouldbesystematicallyimplementedthroughoutthecountry,directedatbothdietaryhabitsandphysicalactivitylevel.

• Interventionstopromoteregularbreakfastconsumptionshouldbeoneoftheapproachesundertaken.

• Nationaldietaryguidelinesshouldincluderecommendationsonconsumingnutritiousfoodsandbeveragesforbreakfastalongwith recommended serving size to help educate children onhowtoachieveabalancedbreakfast.

• Greater efforts must be undertaken to increase nutritioneducationinschoolsonthehealthbenefitsofwholegrainandhowtoidentifywholegrainfoods.Inaddition,stepscouldbe

taken by the regulatory authority in Malaysia to encouragemanufacturerstoaddorincreasewholegraininproducts.

• Participation in physical education should be compulsory foreverychildinschoolandideallyshouldbetaughtbyatrainedteacher.Classesintendedforphysicalactivityeducationshouldbestrictlyutilisedforthispurpose.

• Nutritionistsmustbeassignedtoeffectivelyimplementnutritionrelated activities in schools, including carrying out nutritioneducation activities, various nutrition promotion activities,monitoring and referral of under-and over-nourished childrenandensuringimplementationofschoolcanteenguidelines.

• Parents shouldbe rolemodelsandbeactively involved inallefforts to promote healthy eating and active living amongchildren. Investing in the nutritional wellbeing of childrentodayistheonlywaytoensureahealthiergenerationofadultMalaysianstomorrow.

Recommendations

Tee ES, Mohd Nasir MT, Norimah AK, Hamid Jan JM, Tan SY, Appukutty M, Nurliyana AR, Thielecke F, Hopkins S, Ong MK and Ning C

Nutrition Society of Malaysia MyBreakfast Study Research Committee

For more information, please email Dr Tee E Siong: [email protected]


New children’s hospital in HK in 2018

The Hong Kong Paediatric Society in collaboration withtheHongKongPaediatricFoundationandtheAmerican Academy of Pediatrics (AAP) organized a conference with the theme ‘Consensus on Integrated Child Health - from Hospital to Community’ on 7-8 November 2015.

By all counts, the conference was a success and the discussions involved Paediatricians, nurses, other healthcare workers and, most importantly, policy-makers and politicians. Credit has to be given to Dr Chok-Wan Chan, past-president of APPA and IPA for gelling together these other stakeholders and moderating mature discussions among the attendees.

New children’s hospital policiesAlthough the theme was about transitioning between hospital and community care, it was also about deciding policies for the new children’s hospital in Kai Tak area (where the old airport used to be). Dr Chan’s (and many senior paediatrician’s) vision, and the promise of a former Hong Kong Chief Executive, of a Centre of Excellence in Paediatrics & Child Health with a neurology and rehabilitation centre challenged the new policy of having major subspecialties minus the neuroscience centre. As usual, Dr Chan’s eloquent expression of his vision and recollection of the promise were clearly demonstrated to the audience.

An update on the progress of the Hong Kong Children’s Hospital (HKCH) by Dr Libby Lee, the Chief Manager of the Strategy & Planning Division oftheHospitalAuthorityHeadOfficeshowedtheexpense involved in the hospital as well as the effort put in to the details of the physical building and staff deployment. HKCH aims to enhance the quality of paediatric services in Hong Kong by concentrating expertise, research and teaching with multi-partite involvement.

The medical homeTheAAPwithDrsJaneFoyandThomasKlitznerbroughtthe concept of the medical home, a virtual centre that coordinates and handles the needs of patients with chronic illnesses needing multidisciplinary management. ThatisthebestthatIcouldtrytodescribetheconcept!Even in the US there are not yet many places that use this concept. Although it was an eye-opener, I am still wondering how we can implement such a technology-, cost- and labour-intensive system in our region.

Child health systemsI was invited to give an overview of child health systems in the Asia Pacific Region while Dr Kun-Ling Shen, the President of the Chinese Pediatric Society presented China’ssystem.DrJaneFoyexplainedtheUSsystem.Itwas a good exchange of ideas and thoughts although we all know that what works for one country may not be implemented in another. It is enough to study and adopt each other’s best practices. Dr Chok-Wan Chan and Dr Lilian Wong, President of the Hongkong Paediatric Society with the assistance of Ms Susanna Lee, President oftheAsiaPacificPaediatricNurses’Association,andtheir committees deserve all the credit for organizing such a meaningful event participated by all stakeholders in the making of the new children’s hospital. We in the region wait eagerly for it to open its doors in 2018. CongratulationsHK!2

Zulkifli Ismail [email protected]

Report

The Faculty of ‘Consensus on Integrated Child Health - from Hospital to Community’

Launch of the Children’s Communision

Half the participants in group photo


The changing patterns of paediatric management of common disorders (Part 1)

My favourite moment of the day is after lunch. I sit on my deck chair, on the balcony of my apartment, and look out at the

shimmering blue sea, watch the flotilla

of sleek yachts, the Manly ferry from Circular Quay, and the majestic cruise ships, as they gracefully sail around the Sydney Harbour. I allow my mind to wander, and I often think of my 45 years of practising paediatrics, and how over the years, I had to struggle to adapt to the many changes of managing paediatric disorders. It was this that has prompted me to write this article, which I thought might interest the younger doctors, who are setting out to do paediatrics.

Early YearsI joined the paediatric unit at the General Hospital Penang as a houseman on 1st August 1960. Dr.D.Bowler was my consultant, and Dr. Patmanathan my registrar. I was to alternate weekly night calls with Dr.Pathmanathan. After our first morning ward round, both the consultant and Pathmanathan left me in charge and proceeded with their daily outpatient clinic. I had finished collecting all the blood samples (one of my duties as a houseman), and was in the treatment room (my little office and work room) with my microscope, looking at some blood slides when the nursing sister brought in an 11 month little boy who was screaming in pain. I noticed he was lifting his legs and pointing to his tummy. I asked the mother to sit down and carry him on her lap. He soon settled down. I warmedmyhands(ProfElaineFieldusedtoemphasisethe importance of this) and proceeded to examine him. As I palpated his abdomen, I felt a ‘sausage shaped’ lumpunderthelivermargin!Irememberedasastudentunder Prof. Wong Hock Boon in Singapore, I had done an assignment on intussusception, but I had never seen acase.Iwonderedifthiscouldbeacase!IrangDr.Bowler who immediately came down from his office, examined the boy and patted me on the back. “You arespoton.Itisacaseofintussusception”Herangthesurgeon, who confirmed the diagnosis, and soon the boy was sent to theatre and was successfully operated on.Note:thediagnosiswasclinicalandthepatientwasoperated on successfully.

Since that experience, I had an obsession to rule out the possibility of intussusception, in young children admitted with acute abdominal pain. My interns were taught the gravityofmissingthediagnosis.Overtheyears,therehave been a few close calls, especially with children admitted to the ‘gastro’ ward as cases of dysentery. I

can still remember at least two cases I diagnosed during my morning round in the ‘gastro’ ward.

Surgical vs Barium reductionSurgical reduction was then the accepted management for intussusception. In 1966, when I was training in U.K., at the Hospital of Sick Children, Great OrmondStreet,IstillrememberProf.Wilkinson,professorof paediatric surgery, telling us at a lecture, that in his opinion, surgical reduction was the treatment of choice. He was critical of the Europeans for performing barium enema reduction. Hence I came back from U.K. with the belief that surgical reduction was the gold standard for the management of intussusception, and I referred all my cases to the surgeon for reduction.

In 1977 when I joined the Gleneagles Medical Centre in Penang, and saw my first case of intussusception, Dr Chan, our radiologist, after looking at the plain X-Ray abdomen, suggested barium enema to confirm the diagnosis and to reduce the intussusception. I agreed and we proceeded and he successfully confirmed the diagnosis and reduced the intussusception. He also started using ultrasound as a diagnostic tool before proceeding with the barium enema reduction.

Newer techniquesFromJune1977-March1992wesaw73casesofintussusception and Dr.Chan attempted barium enema reduction in 70 cases. He was successful in 59 of 70 cases with 12 recurrences in 6 cases. I remember we needed 3 attempts on our surgeon’s grandchild before it was successfully reduced. The final success rate was around 69%. I presented our findings at our MPA Meeting in Penang in 1992. When Dr Chan left us, Dr Abdullah, our new radiologist, suggested using air. He pointed out that the Chinese had been very successful with this. We found this technique gave us a higher success rate.

Since the first recorded case of intussusception by Paul Barbette of Amsterdam, in 1674, and Cornelius Velse’s successful operation on a case in 1742, and Samuel Mitchell’s report of the first case of successful air enema reduction in 1836, polemic and bigotry has been raging for years between the proponents of surgical reduction and those who advocated barium/air enema reduction. This impasse has finally been unlocked and today, and most would agree, ultrasound, as a diagnostic tool and air enema reduction would be the treatment of choice. Laparoscopic surgery is now being increasingly attempted when air or barium reduction fails. 2

The Late Datuk Dr N. Paramaesvaran

Remembering

12 • BERITA MPA – FEBRUARY 201612 • BERITA MPA – FEBRUARY 2016

I have been asked a couple of times by fellow colleagues to provide some info to those who are interested to take up paeds as their specialization. Well, to be honest I am still very much new in this field but since the aim of this space is to (insyaAllah) help others, here are some of my personal notes.

ForthisparticularpostIwillwriteonhowtostartyour journey in Paeds through the Membership of Royal College of Paediatrics and Child Health (UK), I will write more on our local Masters programafterIpassmypartI(prayinghard!).

First: Intention!Why Paediatrics? If you think kids are cute and you just love playing with them. That¹s just not enough. In many ways you need to really be-cruel-to-be-kind if you wish to be their doctor (well, I guess like I said I¹m really still very much a neonate in this field). Kids are cute, mysterious in many ways because they won¹t tell you anything but their parents are certainly not cute and they can be painful at times (most of the time actually especially those rude ones).

Second: Application!You need to sign up on: http://www.rcpch.ac.uk/ as all the exam applications are now online, so once you have your own account you are able to register for exams, check your results and many more. Please go through the whole website to learn every single thing about the exam dates(3timesperyearinKLsoPLANyourexamsahead), fees, syllabus, specimen papers and many more.

Third: Studying!Ohgosh,nottherightpersontotalkaboutthistoo as I am the laziest, late bloomer of all. Despite the busy, energy-draining 8-5pm, sometimes after 36hour of being oncall just try to find at least an hour or two to study. Make notes, bring a book just everywhere you go so whenever you are free you can just flip through some pages and try to absorb some stuff.

Some useful (must-have) books for Part I: Paul Gaon Paediatric Exams, A Survival Guide Rachel Sidwell & Mike Thomson Concise Paediatrics PastTest series (Questions, Essential Revision) Basic Medical Science for MRCP Part I

Online resources: Pastest BMJOnexamination Emedicine Uptodate

Fourth: Exams!Notmuchtipsexceptmakealotofduáas(prayers)!Tahajjud!Teachandhelpothers!You can’t possibly know everything, it has a lot to do with luck too so we all need His divine intervention.

Postgraduate examinations are really not like thoseundergraduatedays!Youreallyneedtobeself-driven. If you are not able to help yourself, no onewould!Startnoworregretlater!

Goodluck!2Husna Musa

[email protected]

ReportReport So you want to do Paeds?

ReportReportSitting on SafetyDrive safely & ensure your child’s safety by

using a proper child car seat.

All children must be buckled and seated, those under 13 years old must sit at the back.

Never place a rear-facing car seat in front of an active airbag.

Don’t substitute a booster seat with a cushion; they can slide o�, displace the child & cause strangulation.

Keep your child in the speci�ed car seat until they reach the recommended height & weight limit of the seat.

CUSHION

REAR-FACING BOOSTER SEAT BELTFORWARD-FACING

Straps are snug with one �nger-width of slack; no twists.

Ensure the seatbelt straps/tethers are tight, keeping the car seat in place.

Straps are at shoulder level.

Never leave

your child alone in a car

0 – 2years

2 – 7 4 – 12 8 years

Chest clip is at armpit level.

Position your child with his or her back and bottom �at against the car seat.

Checklist:

years years and above

Brought to you by

Malaysian Association of Kindergartens

National Population and Family Development Board Malaysia

Obstetrical and GynaecologicalSociety of Malaysia

Nutrition Society of Malaysia Malaysian Mental HealthAssociation

Malaysian Psychiatric Association

Malaysian Society of Clinical Psychology

Malaysia’s Pioneer Expert-Driven Educational Programme www.mypositiveparenting.org

Tea

r He

re to

Disp

lay Po

ster in

Clin

ic

#


International Venues

The 28th International Congress of Pediatrics (IPA2016)

Dates : 17 - 22 August 2016Venue : Vancouver Convention Centre, British

Columbia, West CanadaSecretariat:MCICanada/AFEAPhone : 1-604-688-9655 E-mail : [email protected] Website : IPA2016.com

Announcements

26th European Congress of Clinical Microbiology and Infectious Diseases

(ECCMID)Dates : 9 - 12 April 2016 Venue :RAIAmsterdam,NetherlandsTel : + 41 31 528 04 31Fax :+41229069140Email : [email protected] : www.eccmid.org

The 3rd World Congress on Controversies in Pediatrics (CoPedia)

Dates : 31 March - 3 April 2016Venue : Barcelona, SpainWebsite : www.congressmed.com/copedia

Neonatal Transport Workshop in conjunction with 8th National Paediatric

Research Conference Date : 27-28February2016Venue : Auditorium, Pusat Perubatan Universiti Kebangsaan Malaysia, Kuala LumpurTel : (603) 4023 4700, 4025 4700, 4025 3700Email :[email protected] [email protected] (registration)Website :www.acadmed.org.my/NPRC2016

12th National Symposium On Adolescent Health (NSOAH)

Date : 1 - 3 April 2016 Venue : M Suites Hotel, Johor Bahru, JohorTheme : E-Teens: Empowering Teens in the Digital AgeOrganiser :MAAH(MalaysianAssociationfor Adolescent Health)Tel/Fax :03-40502422Email : [email protected] : www.maah.org.my

11th International Symposium on Pediatric Pain

Date : 6 - 7 July 2017 Venue : Kuala Lumpur, MalaysiaTheme : Understanding Pain in Children - Take theFirstStepTel : +603 4043 4700Email : [email protected] : www.ispp2017.org

Local Venues

2nd International Neonatology Association Conference (INAC 2016)

Date : 15 - 17 July 2016 Venue : Vienna, Austria Email : [email protected] : www.worldneonatology.com

49th Annual Meeting of the European Society for Paediatric Gastroenterology,

Hepatology and NutritionDates : 25 - 28 May 2016Venue : Megaron Athens International Conference Center, Greece Tel : +44 (0) 1730 715 230Email : [email protected] : www.espghan.org

New Life MeMbersDr Suria Emilia Suhana Othman TanNo.40,Persiaran Seksyen 3/10 Bandar Putra Bertam13200 Kepala BatasPulau Pinang

Dr Fairuz Nazri Abd RahmanJabatan PsikiatriUKM Medical Centre56000 Cheras, Kuala Lumpur

Dr Melanie MajahamA-7-8, Tamarind CondoNo.2,JalanSentulIndah51100 Kuala Lumpur

Dr Chan Mei Yan2216, Lorong Asap Bakar Bota05100 Alor SetarKedah

Dr Shereen Toh May Yi1-W-7-3, Palm PalladiumLebuh Minden Satu11700 GelugorPulau Pinang

Dr Teng Ay Jiuan1-W-7-3, Palm PalladiumLebuh Minden Satu11700 GelugorPulau Pinang

Dr Ang Ming Ping17, Lorong Seri Gemilang 4Taman Seri Gemilang14000 Bukit MertajamPulau Pinang

Dr Noor Arliena Mat Amin4, Jalan Pegaga U12/12Section U12, Desa Alam40170 Shah AlamSelangor

Dr Yeoh Chiou YenNo.48,JalanAngsana1Bandar Botanic41200 KlangSelangor

New OrdiNary MeMbersDr Kama Azura JamilNo.1,JalanIP11Taman Indah Puteri43900 SepangSelangor

5th Global Congress for Consensus in Pediatrics and Child Health (CIP 2016)

Dates : 3 - 6 March 2016Venue : Xi’an, ChinaTel : +972(0)3-576-7737Email : [email protected] : http://2016.cipediatrics.org/

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